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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE IfiSIGJ COMMENTS oWNER BUILDER DELCAIIATION
<br />I hcrcby amrm undcr rcnally {,f pcriury lhar I !.i.mpr rs,'n rhc C.nka.los Li.ctsc ljw lor lhc tollowing rcNrn (S(r0ll s
<br />tsu\incs lnd Prolt$ion Codc) Any Ciry or Cuunry whi.h rcluncs 0 Frmn Io con(tucr. ahs. im 0w. dcnBlish '{ rcluir my
<br />stu.rur., pri.rro ns ixsuan c. also rcquircs lhc ol'PlicMl forsuchrEmn'o filctrsisn d$dc'mN Ih0' lEor shc t licenrd pursurnr
<br />t' rhe F,{hn,ns ol rhc Conr.ackn s Licc.{d Li* lchnprur 9, Connnckins uilh Sccrt,n I)(n ot Dirisbn I ollhc Businc$ rnd
<br />Pbrc*ions Codc) .r rh,r h... sh. iscxcmpl thcrclrommd rhe bssn lor rhc a ll.gctl cxcnDr ion. An, viol ionofsdi,nT0ll5 byanl
<br />opt'lic.nt for r rcnnir suhj(ls rhc trprli.Dtrr t,a.ivilFnaxyofnDr nx'rcthm nvc hund,cd dollB (S5m)
<br />l. !s owncr oirhc pmpcn], or mrcmllortr wirh sngc\ r rhtn $Ij comn trs0tiotr. willdo ih. *o* lnd rh. nMurc is mr
<br />ide'xnrl or oflcrcd fu slc ( S( 7014, Buim$ nnd Proltssi,)ns ( fllc Thc Ci,nttrof s Liccn{ ti* docs n.r ,rlly t) nn osrcr of
<br />rh. nmlcdy wh) hoildsor inpn)Ks rh.d[ md who dcs strh wo* [n.s.lior hcrclfor rhftuln his ot hcr o*ncmPlormr.
<br />pmvidcd rhsr sxch inpmv.mnls m mr inlcndcn or oficred tor {h li. hotkr. rh. buildinS or nq'olcmnl is $ld tirhin oic ,w
<br />of.onplctiotr, ltE Oprcr Buills willhlvc rlE hurden otfovins lnd lE ordr did d hoild or iDProvc thc pmrcry r(, rht pu{x'* or
<br />-1.!so*ncrofrh.pmI.ny.am.r.lurivclycontr.crir8wirhliccnscd(nnrrct,^(,.o
<br />srfl.r rlr l)lojr{ (Scc 7l}4,1, Busim\\
<br />rnd PrcrNsi Codc IhcConrncr{tr\ Liccn{c Lr* 1n6 noi,mlyb Mowncr.foropcnysho huilds ornnpn,vc\ rh.rco.,
<br />lnd rho coni@rs for \och pn,t crsqirhaqrnrm.hn\) li(tr{d pusurnr lothcConrricroir l-iccnsc Ltr*)
<br />-l
<br />rnrcxcn'l undcr Sc.rn,
<br />Dole O*o.r
<br />rvoRt(srL\' coNrPENsAiloN
<br />DECLAMIIA!
<br />I hcrcby !flnm under pcDlrroipc.julyo't.rrht r(,lbwins d..l.r.riotrs
<br />-l
<br />hrvc u.t*ill n,air JinrCcnill. c ofCotrsctrr tu Sclf ltrsur. lbr sorlcri ..nlP.nurior. a\ lxtridcdlorbySccrion.lT(Xlolrh.
<br />dor
<br />cdc. rq rhc nc'hlnmc or rh. tr'n l hr whtr h rhc r' r'!'{tr.,|
<br />Ul-rha,. "na
<br />*, tt m nnn wrlcr' (nn'I'cn\orion in.ururcc- ss rcquidd by s..rion :l?(x) oi rhc I jh.r Codc. td rh. dnnmn . ol
<br />rhc sork tur shi.[ rhis rirn ir i\ i$ucn Mys.rtc6 .on,pcn\rri{,n in\urr .c.nrifir Fli.y nunrhcr arc
<br />l,,l() t 'l (<+7
<br />l.cdilithl'l hlhc p.rl'om!'ncc {)fuhc wo r.r whi.h ihi\ Nnnir hlsuql- I firll nor cnrPbr ,ny F6.n ir.trynrnnct
<br />v' * r, hN,nf, \uhjdci Io rls workc6 .onr!.ns.rion hw\ ofcalir'orni!. lnd lsrcc rhar irl shtuld bc.orN subiccr n, rlrc
<br />sorkc^ cohp.nsrri.n pn,rhio.s ofSeri.n]7moi rhc l-$or Codc- I \hrll. tu hsirh comtly s irh llx)s povi\n,ns
<br />nr ion covcrug. ir utrh*trl- r d shill \ubiccr nn cnpl,,$r ki rininrl Ntrnlric( nt
<br />b otu hu dr.d thonsrnd dollds l$100.{xx)). in rdJir o rhe .o{ rl conrFtrq i,nr. dtr rgr\ r\ f^idcd Lt rh.
<br />i'clc{nlrlir'rl.\ldc\
<br />",,", !, {ral r8
<br />I hcrctylnn utucr pcnulryoapcrju.y rhd I dm lkcn*i undcr pmvision oiChatlcr 9 (.onnrming wirh Scclion Tlxlo) oll)ivni.n.r
<br />of ihc Busimssand Prolcssiors Codc, and nlyli..n\c il in full iar.c xlcficcr.
<br />bassrt*, b(t41tN
<br />CQNSIBUj:TONIIiNIIdQIIiENEI
<br />I lrrcby afinn trndcr 0ctrrlryoil.rjuryrhrr lhcrc ir ! con{ru.rion kndi g agcky Lr rh. Fnnnnanc. ofrh. sork for which rhi\ |Ennir i\
<br />i\\ucJ (Scc .1097, Ci! C ).
<br />Lcndcr'. Addrc*
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<br />AIPIICAXLDICLAIAII{I!
<br />I isr$y unim !ndc. Fidny or lcrrury oic ofrhc folloqin-! dcrtrllions
<br />Dcmolilio. Pcrnrils'Asbcsros Norilic!rion Fcdcrsl Rdg!larn,ns (Ti'lc40. Parto
<br />Rcquiml tdlci ol Norificolion
<br />-l
<br />cc.rilyrhlr rhc Ld.tul rceulnrions rcBrding asbcsos rennvtrl rc nor rlplic lcb rhir tmrccr
<br />0.1 *r'rv rr,"r I r'"* *"a,r'" nnrrlKrii,n sJd {arc rhdr rhc trh,vc irronmrion is corccr I lsrcc rDd,n l, u'irh lllciryand (i,unr,
<br />(dlnamcs lnd Shr.liw\Elrrnsn, bu'ldrnE .oh{rucrni. drl hcrcbyoultoriz! rcpesc arilcsofrhkCilyandCou.lyrocmdxFnrhc
<br />rl C rctrrtr .d |[,Jicny tur n\,.cri,,
<br />ApDlicinl or .\,!cnl Si*n$lure ituL6
<br />aIra){
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVlnsu lation
<br />Roof Sheathino
<br />Shear Wall
<br />Framing
<br />ln s u lation/E ne rqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It4asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />FIood Zone Certil
<br />I
<br />FINAL ElsT ltP llrrltvel ,/ 7'
<br />Certif icate ot Occu nc
<br />Notes, Remarks, Etc
<br />Set Backs
<br />.-"*".,K
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